Mild Hypertransaminasemia in Primary Care

The liver enzymes, alanine transaminase (ALT) or aspartate transaminase (AST), are commonly used in clinical practice as screening as well as diagnostic tests for liver diseases. ALT is more specific for liver injury than AST and has been shown to be a good predictor of liver related and all-cause mortality. Asymptomatic mild hypertransaminasemia (i.e., less than five times normal) is a common finding in primary care and this could be attributed to serious underlying condition or has transient and benign cause. Unfortunately, there are no good literatures available on the cost-effectiveness of evaluating patients with asymptomatic mild hypertransaminasemia. However, if the history and physical examination do not suggest a clear cause, a stepwise approach should be initiated based on pretest probability of the underlying liver disease. Nonalcoholic fatty liver disease is becoming the most common cause of mild hypertransaminasemia worldwide. Other causes include alcohol abuse, medications, and hepatitis B and C. Less common causes include hemochromatosis, α1-antitrypsin deficiency, autoimmune hepatitis, and Wilson's disease. Nonhepatic causes such as celiac disease, thyroid, and muscle disorders should be considered in the differential diagnosis. Referral to a specialist and a possible liver biopsy should be considered if persistent hypertransaminasemia for six months or more of unclear etiology. 1. Introduction The term “liver function tests (LFT)” is commonly used in clinical practice when referring to liver enzymes. However this term is misleading since these tests primarily assess liver injury rather than liver function. In addition, this term also implies that these tests are solely of hepatic origin, but in fact, they are not always specific for the liver. The serum aminotransaminases, alanine transaminase (ALT, formally serum glutamic-pyruvic transaminase (SGPT)) and aspartate transaminase (AST, formally serum glutamic-oxaloacetic transaminase (SGOT)), are frequently obtained in primary care for screening and diagnosis of liver diseases and have therefore led to increased number of asymptomatic patients with mild hypertransaminasemia (i.e., less than five times the upper limit of normal) [1]. A population-based survey in the United States found that hypertransaminasemia was present in 8.9 percent of the population [2]. Although the majority of these individuals will have benign conditions, a subgroup will have underlying significant liver diseases that require further evaluation and therapeutic intervention. An audit of primary care practices found